Basic Information
| Provider Information | |||||||||
| NPI: | 1326008871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALT | ||||||||
| FirstName: | BROOKE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 GARDEN CTR | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800201776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034650401 | ||||||||
| FaxNumber: | 3034042317 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 BALSAM AVE | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034402273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 11/28/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 22657 | CO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 21686734 | 05 | CO | MEDICAID |